Transcatheter aortic valve implantation (TAVI) has emerged as an effective and safe treatment for patients with symptomatic aortic stenosis. The indication to TAVI should be agreed upon by a Heart Team, and the procedure should be performed in centers with on-site cardiac surgery. However, TAVI complications requiring emergent cardiac surgery (ECS) have become very rare. Concurrently, access disparities and prolonged waiting times are pressing issues due to increasing clinical demand of TAVI. Many solutions have been proposed and one of them is the possibility of performing TAVI in centers without on-site cardiac surgery. The Transcatheter Aortic-Valve Implantation with or without on-site Cardiac Surgery (TRACS) trial is a prospective, randomized, multicenter, open-label study with blinded adjudicated evaluation of outcomes. Patients with symptomatic severe aortic stenosis and deemed inoperable, at high surgical risk, or presenting with at least 1 clinical factor compromising the benefit/risk ratio for ECS, will be randomized to undergo TAVI either in centers with or without on-site cardiac surgery. The primary endpoint will be the composite occurrence of all-cause death, stroke, and hospital readmission for cardiovascular causes at one year. The safety endpoint will include death attributable to periprocedural complications actionable by ECS. The study aims to enroll 566 patients. The TRACS trial aims to address critical gaps in knowledge regarding the safety and efficacy of TAVI procedures performed in centers without on-site cardiac surgery, potentially improving access and outcomes for high-risk patients. ClinicalTrials.gov NCT05751577.

Nowadays, coronary computed tomography angiography (CCTA) has a role of paramount importance in the diagnostic algorithm of ischemic heart disease (IHD), both in stable coronary artery disease (CAD) and acute chest pain. Alongside the quantification of obstructive coronary artery disease, the recent technologic developments in CCTA provide additional relevant information that can be considered as “novel markers” for risk stratification in different settings, including ischemic heart disease, atrial fibrillation, and myocardial inflammation. These markers include: (i) epicardial adipose tissue (EAT), associated with plaque development and the occurrence of arrhythmias; (ii) late iodine enhancement (LIE), which allows the identification of myocardial fibrosis; and (iii) plaque characterization, which provides data about plaque vulnerability. In the precision medicine era, these emerging markers should be integrated into CCTA evaluation to allow for the bespoke interventional and pharmacological management of each patient.

Severe aortic stenosis represents a significant prognostic burden, particularly in symptomatic patients. The advent of transcatheter aortic valve replacement (TAVR) has revolutionized the treatment of patients previously considered ineligible for surgical aortic valve replacement (SAVR). TAVR provides a relatively safe intervention that leads to improvements in survival, symptoms, and functional status within months of implantation. A major complication following TAVR is the occurrence of paravalvular leaks (PVLs), which have been associated with increased mortality and higher rates of heart failure-related hospitalizations. PVLs refer to abnormal blood flow between the implanted valve and the aortic wall, which can compromise the functionality of the device. Careful pre-procedural planning enables the identification of patients at higher risk for PVL development. Although the incidence of PVLs has decreased with the introduction of newer-generation transcatheter valves, the condition remains clinically relevant. Due to the complex anatomy of the aortic valve apparatus and interference from the prosthetic frame, accurate evaluation of PVLs requires a multimodal diagnostic approach. Current evidence on PVL management is limited. In most cases, a conservative approach is adopted, while interventional strategies (such as pre- and post-dilatation, percutaneous PVL closure, and TAVR-in-TAVR) are reserved for selected patients. We performed a systematic literature review to summarize the incidence, predictors, diagnostic techniques, and management strategies of PVLs following TAVR.

The aim of this review is to identify possible structural abnormalities of BrS and their potential association with symptoms, risk stratification, and prognosis. (1) Background: BrS has always been considered a purely electrical disease and imaging techniques do not currently play a specific role in the diagnosis of this arrhythmic syndrome. Some authors have recently hypothesized the presence of structural and functional abnormalities. Therefore, several studies investigated the presence of pathological features in echocardiography and cardiac magnetic resonance imaging (MRI) in patients with BrS, but results were controversial. (2) Methods: We performed a systematic review of the literature on the spectrum of features detected by echocardiography and cardiac MRI. Articles were searched in Pubmed, Cochrane Library, and Biomed Central. Only papers published in English and in peer-reviewed journals up to November 2021 were selected. After an initial evaluation, 596 records were screened; the literature search identified 19 relevant articles. (3) Results: The imaging findings associated with BrS were as follows: right ventricular dilation, right ventricular wall motion abnormalities, delayed right ventricular contraction, speckle and feature tracking abnormalities, late gadolinium enhancement, and fat infiltration in the right ventricle. Furthermore, these features emerged more frequently in patients carrying the genetic mutation on the sodium voltage-gated channel α-subunit 5 (SCN5A) gene. (4) Conclusions: Specific imaging features detected by echocardiography and cardiac magnetic resonance are associated with BrS. However, this population appears to be heterogeneous and imaging anomalies emerged to be more frequent in patients carrying genetic mutations of SCN5A. Future studies with an evaluation of BrS patients are needed to identify the specific association linking the Brugada pattern, imaging abnormalities and their possible correlation with prognosis.

Background: Little evidence to date has described the feasibility and diagnostic accuracy of coronary computed tomography angiography (CCTA) with noninvasive fractional flow reserve (CT-FFR) in coronary vessels with resorbable magnesium scaffold (RMS). Methods: The SHERPA-MAGIC is a prospective study enrolling patients receiving RMS. The present analysis considered patients undergoing CCTA 18 months after the index procedure. CCTA images were employed to investigate reabsorption status, luminal measurements, and noninvasive FFR. Three-year follow-up was available for all patients. Results: Overall, 26 patients with a total of 29 coronary arteries treated with 35 RMS were considered. The most frequently involved vessel was left anterior descendent (LAD). Median stent length was 25 (20–25) mm, with a median diameter of 3 (3–3.5) mm. At 18-month CCTA, all scaffolded segments were patent. Complete RMS reabsorption was observed in 27 (93%, 95% CI 77–99%) cases. Median minimal lumen diameter (MLD) and area (MLA) of the scaffolded segments were 2.5 [2.1–2.8] mm and 6.4 [4.4–8.4] mm², respectively. Median CT-FFR was 0.88 [0.81–0.91]. Only one (3.5%) vessel showed a flow-limiting CT-FFR value ≤0.80. During the 3-year follow-up, only one (4%) adverse event was observed. Conclusions: In patients undergoing RMS implantation, CCTA including noninvasive CT-FFR evaluation is feasible and allows investigation of long-term RMS performance.

Background: Myocardial bridge (MB) is a frequent coronary artery anomaly. The aims of this study are to describe the use of antiplatelet therapy (APT) in a cohort of patients with MB and assess its impact on ischemic and bleeding events. Methods: The RIALTO (Myocardial Bridge Evaluation Towards Personalized Medicine) registry (ID: NCT05111418) is an ambispective multicenter observational registry, enrolling patients with a clinical indication to coronary angiography and evidence of MB. The present analysis included patients with MB without any preexisting indication for APT/anticoagulant therapy according to guidelines. Patients were categorized into 2 groups: single APT or no APT based on discharge prescriptions. The primary end point was the time to first occurrence of net adverse clinical events, defined as a composite of cardiovascular death, nonfatal myocardial infarction, unplanned or elective coronary angiography, ischemic cerebrovascular events, and any bleeding. Results: Out of 486 enrolled patients with MB, 221 (mean age: 60 years, 66% male) were included in this analysis. One hundred and forty‐one patients (64%) received single APT. At a median follow‐up of 1661 days, patients with MB receiving single APT had a higher rate of net adverse clinical events (adjusted hazard ratio [aHR], 6.2; P =0.03), mainly driven by a higher rate of minor bleeding events (aHR, 10.58; P =0.02), with no difference regarding ischemic events. Results were consistent after 1:1 propensity‐score matching sensitivity analyses. Conclusions: The prescription of single APT is common in patients with MB, and it seems to be associated with an increased risk of bleeding, in the absence of a beneficial effect on ischemic events.